Drug Court Practitioner

February 2016 Fact SheetVol. XI, No. 1

Understanding and Detecting Prescription Drug Misuse and Misuse Disorders By Sandra Lapham, MD, MPH, DFASAM Senior Research Scientist, Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation

his fact sheet is designed for court professionals. It describes prescription T drug misuse and provides information on: • The attributes of the most commonly misused and addictive prescription drugs • The extent and consequences of misuse • Side effects and toxicity • Characteristics of those who are most likely to misuse prescription drugs • Signs and symptoms of misuse • Ways to identify and treat those who may have developed a drug use disorder, including a section on medication-assisted treatment of opioid use disorder • Educational and technical assistance resources on this topic from SAMHSA and other organizations

Prescription Drug Misuse drug causes (SAMHSA, 2012). This definition and the Most Commonly covers a wide range of behaviors, from using someone else’s medication to address a Misused Drugs legitimate medical need to misusing prescription The Substance Abuse and Mental Health medications to stay awake, get to sleep, calm Services Administration (SAMHSA) defines down, enhance job or athletic performance, or nonmedical prescription drug misuse as the change one’s mood. use of prescription pain relievers, tranquilizers, People who misuse prescription medications stimulants, sedatives, and other prescription may not understand that, although drugs for drugs in a way other than prescribed, such as treating pain and other medical conditions are for perceived medical need or for the feeling the generally safe when taken as prescribed, they Table 1. Commonly Misused Opioids and Their Applications

Generic name Brand name(s) Used to treat

OxyContin, Percodan, Percocet, Acute and long-term oxycodone Roxicet, Tylox pain relief

Lorcet, Lortab, Vicodin, Acute and long-term/ hydrocodone Vicoprofen chronic pain relief

hydromorphone Dilaudid Pain relief

Astramorph, Avinza, Duramorph, morphine Post-surgical pain relief Kadian, MS Contin, Roxanol

codeine various Pain relief, cough, diarrhea can be dangerous if they are not prescribed for the Opioid Pain Relievers person taking them or not taken as prescribed by Opioids are the most commonly misused their health care provider. prescription drugs. They act on the limbic system A national survey conducted in 2013 shows that (which controls emotions), the brain stem (which prescription drug misuse is a serious public health controls autonomic body functions), and the problem. Approximately 6.5 million (2.5%) of spinal cord (which receives sensory information Americans aged 12 years and older admitted to from the body). As shown in Table 1, medications in this class include hydrocodone (e.g., Vicodin), using prescription drugs nonmedically in the oxycodone (e.g., OxyContin, Percocet), morphine past month (SAMHSA, 2014b). Nonmedical (e.g., Kadian, Avinza), codeine, and related prescription use is especially common among those drugs. Hydrocodone products are the drugs most with chronic pain, teenagers and young adults, and commonly prescribed for a variety of painful those with a history of addiction or other mental conditions, including acute injuries and dental health problems, such as depression and anxiety procedures, as well as chronic conditions, such (Compton & Volkow, 2006). as cancer and arthritis. Morphine is often used before and after surgical procedures to alleviate Prescribed medications that are commonly misused severe pain. Codeine, a milder pain reliever, is in an ongoing or dangerous manner are called often prescribed for less severe pain. In addition psychoactive drugs, as they all affect the brain and to their pain-relieving properties, some of these can have a profound effect on mental states and drugs—codeine and diphenoxylate (Lomotil), processes. The most commonly misused types of for example—can be used to relieve coughs and medications are central nervous system depressants severe diarrhea (National Institute on Drug Abuse (“downers”), which include both opioids and [NIDA], 2014). sedative-hypnotics (tranquilizers and sedatives; Opioid painkillers reduce pain often without Manchikanti, 2006). A third class of drugs—central eliminating its cause. They produce sedation, nervous system stimulants (“uppers”)—are also euphoria, and respiratory depression, and they slow commonly misused. gut function, which frequently leads to constipation.

2 NDCI: The Professional Services Branch of NADCP Understanding and Detecting Prescription Drug Misuse and Misuse Disorders

Peak effects generally are reached in 10 minutes if taken Unfortunately, prescription opioid misusers are intravenously, 30 to 45 minutes with an intramuscular increasingly switching to or supplementing with heroin, injection, and 90 minutes by mouth. The absorption of in part due to actions against “doctor shoppers” and “pill toxic doses by mouth may take longer because the retarding mills.” Heroin often is readily available and costs much of gut movement delays drug absorption. less than prescription opioids (Unick, Rosenblum, Mars, & Ciccarone, 2013). Extent and Consequences of Misuse Since 2003, more overdose deaths have involved Side Effects and Toxicity of Opioids prescription opioids than heroin. This epidemic parallels The chief hazard associated with opioid painkillers is the huge increase in the number of prescriptions written respiratory depression (Teater, 2015). These medications for opioid medications over the past decade. Enough is are dangerous because the difference between the amount prescribed annually to give every person in the United needed to feel the effects and a fatal dose is small and States a typical 5 mg dose of Vicodin (hydrocodone and unpredictable. Other drugs—such as alcohol, tranquilizers, acetaminophen) every four hours for three weeks. A Nation barbiturate sedatives (found in sleeping pills and anti- in Pain, a report published by Express Scripts (2014), anxiety medications), and some muscle relaxants that analyzes prescription opioid use in the U.S. from 2009 cause drowsiness (especially carisoprodol [Soma]; Jenkins to 2013. Although the number of Americans using pain et al., 2011)—increase the respiratory depression caused medications long term did not increase over this period, by opioids. So if someone takes their usual dose of opioids, the volume of pain medication sold increased significantly. but adds alcohol or tranquilizers, they may pass out, stop Nearly half of patients who took opioid pain relievers for breathing, and die. more than 30 days in their first year of use continued to Opioids are broken down in the body into harmless use, or misuse, the drugs for three years or more. Almost compounds over time, but the time differs by drug. As a 50% of these patients were taking only short-acting result, mixing extended-release and long-acting opioids can opioids, putting them at higher risk for problematic use. be deadly. And the pain-relieving and euphoria-inducing Two-thirds of patients on these medication mixtures were aspect of opioids may wear off sooner than the respiratory- prescribed the drugs by two or more physicians, and nearly depressant effect. 40% filled their prescriptions at more than one pharmacy. In addition to opioids, nearly one in three patients were Signs of opioid overdose include slowed, obstructed, or taking benzodiazepines, 28% were taking muscle relaxants, stopped breathing; sleepiness progressing to stupor or coma; and 8% were combining all three. Additionally, 27% were weak, floppy muscles; cold and clammy skin; pinpoint taking multiple opioid pain treatments at the same time. pupils; slow heart rate; dangerously low blood pressure; Small southeastern cities had the highest rates of pain and death. Sudden lung injury, uncontrollable seizures, and medication use (Express Scripts, 2014). heart damage can also occur, although less commonly. In response to the epidemic of opioid-related overdose Tolerance is a universal effect of opioids and other drugs deaths, manufacturers have reformulated some of the that leads to a need for increasing dosages to maintain commonly prescribed opioids to deter abuse. Moreover, the drug’s effects. It quickly develops into physiological the public health community has responded to the issue dependence leading to a withdrawal syndrome, unless by educating physicians, implementing prescription the patient gradually tapers down. This process can monitoring programs, modifying drugs to reduce their occur in any opioid user—those who take opioids potential for misuse, and reducing online sources of post-operatively for pain relief as well as persons who prescription opioids (CDC, 2007). The abuse-deterrent misuse them illicitly. Once tolerant and dependent, reformulation of OxyContin, combined with many many chronic users may have a hard time stopping due environmental interventions, has led to reduced availability to the physiological withdrawal symptoms. However, of the most desired non–abuse deterrent formulations. this does not mean such a person has developed an

Drug Court Practitioner Fact Sheet 3 Another adverse effect of the chronic use of opioids Common Signs of Opioid is that, when taken for long periods, opioids may actually increase the body’s perception of pain. Overdose This can lead to a feedback loop: need for higher • Slowed, obstructed, or and higher doses, creating more and more risk of stopped breathing overdose while also increasing pain. • Sleepiness progressing Finally, opioid use affects an unborn fetus. Opioids to stupor or coma pass through the placenta and can cause birth • Weak, floppy muscles defects and behavioral problems in babies born to • Cold and clammy skin women who have used these drugs during their • Pinpoint pupils pregnancy, even if they used them as prescribed. Birth defects that can be caused by opioids include • Slow heart rate spina bifida (brain or spinal cord abnormalities), • Dangerously low blood pressure heart defects, and glaucoma (American Congress of Obstetricians and Gynecologists [ACOG] Committee on Health Care for Underserved opioid use disorder (the term now used in place Women, 2012; Broussard et al., 2011). Babies of abuse or dependence).1 Opioid use disorder is born to mothers who use opioids during their characterized by additional symptoms.2 pregnancy may be physically dependent on the drugs and show withdrawal symptoms after People who are chronic opioid users feel less effect birth. This is called neonatal abstinence syndrome per given dose—and their bodies can tolerate more (NAS). Symptoms of NAS include low birth weight, of the drug—than their nonusing counterparts. A respiratory problems, feeding difficulties, seizures, common overdose death scenario among those excessive crying and sucking, tremors, vomiting, who take opioids to get high occurs when, due to breathing problems, disturbed sleep, sweating, tolerance, they increase the dose to get a rush, not irritability, and fever (ACOG, 2012; U.S. National realizing they are not tolerant to the respiratory- Library of Medicine, n.d.). depression effects. The biological mechanisms of tolerance are complex. Different forms of tolerance Pregnant women who have been misusing opioids regularly must undergo opioid replacement therapy have different mechanisms of action. In addition, with methadone or buprenorphine, since stopping tolerance may not be the same for different opioids. use will cause the fetus to experience potentially Other adverse effects of opioids include risk fatal withdrawal symptoms. Both buprenorphine of physiological dependence and opioid use and methadone have been deemed safe for opioid disorder, cognitive impairment, reduced levels addiction treatment of pregnant women, although of sex hormones, brain (neuronal) changes, the babies often will be born with NAS and must be impaired healing, reduced body or muscular gradually weaned off the drug (ACOG, 2012). NAS coordination, and exacerbation of obstructive symptoms appear to be milder with buprenorphine sleep apnea symptoms. (Jones et al., 2010; Unger et al., 2011).

1 “Substance use disorder in DSM-5 combines the DSM-IV categories of substance abuse and substance dependence into a single disorder [drug use disorder] measured on a continuum from mild to severe. Each specific substance . . . is addressed as a separate use disorder (e.g., alcohol use disorder, stimulant use disorder, etc.), but nearly all substances are diagnosed based on the same overarching criteria” (APA, 2013b).

2  DSM-5 contains an extensive list of symptoms. Having two or three symptoms over a 12-month period is classified as mild disease; four to five symptoms, moderate disease; and six or more symptoms, severe disease. The physical dependence and drug withdrawal criteria are not considered to be met for those individuals taking opioids only as prescribed under appropriate medical supervision (APA, 2013a).

4 NDCI: The Professional Services Branch of NADCP Understanding and Detecting Prescription Drug Misuse and Misuse Disorders

Who Is Most at Risk of an Opioid Overdose? Medication-Assisted Treatment of Opioid Use Disorders The two main populations in the United States at risk for prescription drug overdose are the approximately 9 million Some 12 million people reported using prescription people who report long-term medical use of opioids and the painkillers nonmedically in 2010 (SAMHSA, 2011). Of roughly 5 million who report nonmedical use (i.e., use without these, an estimated 15% qualify for a diagnosis of opioid a prescription or medical need) in the past month (CDC, use disorder and would benefit from treatment. Nevertheless, 2012). Those at particularly high risk include people taking medication-assisted treatment (MAT) has been used in fewer than half of treatment facilities (Knudsen, Abraham, & opioid medications for the first time; those taking multiple Roman, 2011). forms of opioids or who mix them with alcohol, barbiturates, or tranquilizers; and those with sleep apnea, heart failure, What Is MAT? obesity, severe asthma, or respiratory conditions (Webster Medication-assisted treatment is a corrective—but not et al., 2011). In the U.S., overdose deaths most commonly a curative—treatment for opioid use disorder. The most result from combinations of substances—mixtures of opioids, effective MATs used to treat opioid use disorder are alcohol, benzodiazepines, sedatives, stimulants, and cannabis, methadone (Dolophine, Methadose) and buprenorphine with the combination of benzodiazepines plus opioids being (Suboxone, Zubsolv). Although they are classified as opioids, particularly toxic (Jones, Mogali, & Comer, 2012). these long-acting medications, when taken as prescribed, do The following populations are especially vulnerable to not get the person taking them high. Like other opioids, prescription opioid overdose (National Center for Injury they bind to the body’s natural opioid receptors, but they are less addictive. When taken appropriately, methadone Prevention and Control, 2011): and buprenorphine can help those in therapy feel normal • People who obtain multiple controlled substance and live normal lives. For optimal results, patients should prescriptions from multiple providers—a practice known also participate in a comprehensive treatment program that as doctor shopping. includes counseling and social support (SAMHSA, 2015a). People who take high daily dosages of prescription • People taking methadone to treat opioid addiction must painkillers and those who misuse multiple abuse-prone receive the medication under the supervision of a physician. prescription drugs. By law, methadone can be dispensed only through an opioid • Low-income people on Medicaid and those living in rural treatment program certified by SAMHSA. After a period areas. People on Medicaid are prescribed painkillers at of stability (based on progress and proven, consistent twice the rate of non-Medicaid patients and are at six times compliance with the medication dosage), patients may be the risk of prescription painkiller overdose. allowed to take methadone at home between program visits (SAMHSA, 2015c). • People with mental illness and those with a history of substance abuse. Unlike methadone treatment, buprenorphine may be prescribed and dispensed in physician offices, significantly Who Is Most at Risk of an Opioid Use Disorder? increasing treatment access. It is the first medication for treating opioid use disorder that can legally be dispensed in The main risk factors for developing an opioid use disorder in this way. Under the Drug Addiction Treatment Act of 2000, the general population are also the most obvious: a history of qualified U.S. physicians can offer buprenorphine for opioid substance addiction and a history of other psychiatric disorders, use disorder in their offices, community hospitals, health particularly mood or anxiety disorders (Sullivan, Edlund, departments, and correctional facilities (SAMHSA, 2015b). Zhang, Unützer, & Wells, 2006). The risk factors for opioid Buprenorphine has a high affinity to the opioid receptors; misuse among those taking opioids for chronic pain include thus, it occupies the receptors at relatively low doses. As a youth, past cocaine use, drug or impaired driving conviction, result, it prevents someone from going into opioid withdrawal and past alcohol use disorder or heavy use (Ives et al., 2006). but not necessarily at a dose that triggers an opioid high.

Drug Court Practitioner Fact Sheet 5 Because methadone and buprenorphine are rates following treatment with sustained-release opioids, some see prescribing them as “giving naltrexone are lower than one-year retention drugs to drug addicts.” This is not the case. These rates in methadone maintenance (Bart, 2011). drugs relieve narcotic craving, prevent symptoms of Therefore, reviews of controlled studies conclude opioid withdrawal, and block the euphoric effects that more evidence is needed to justify its use. associated with heroin and other more powerful Those highly motivated to comply with treatment, narcotic medications (Joseph, Stancliff, & Langrod, such as employees under a treatment plan or 2000). The medications are usually prescribed on people taking the extended release form under an ongoing basis, similar to taking a medication for court supervision, can do well (“Treating opiate high blood pressure. addiction,” 2005). Effectiveness of these interventions is currently well documented in literature reviews by established Benefits of MAT researchers and clinicians (Volkow, Frieden, MAT has proven effective in helping patients Hyde, & Cha, 2014). Nonetheless, because these recover from opioid addiction. When prescribed medications are opioids, they can be misused, and monitored properly, methadone and particularly by people who are not tolerant to the buprenorphine are safe and cost-effective, and 3 drugs’ effects. Naloxone is added to buprenorphine greatly reduce the risk of overdose (Schwartz et al., to decrease the likelihood of diversion and 2013). Other benefits include: misuse of the combination drug product. When • Reduced likelihood of relapse these products are taken as sublingual tablets, buprenorphine’s opioid effects dominate, while • Improved social functioning naloxone blocks opioid withdrawal. If the • Lower risks of infectious-disease transmission sublingual tablets are crushed and injected, through avoidance of illicitly obtained injectable however, the naloxone effect dominates and can drugs bring on opioid withdrawal. • Reduced criminal activities, as money is no Other medications approved to treat opioid longer needed to support an addiction use disorders include oral naltrexone (ReVia, Depade) and naltrexone sustained-release In 2014, the directors of the National Institute injection (Vivitrol). Naltrexone binds strongly on Drug Abuse within the National Institutes to the body’s opioid receptors and reverses of Health, the Centers for Disease Control and the effects of opioids. This reduces opioid use Prevention, and SAMHSA, as well as the chief because people taking these medications don’t medical officer for the Center for Medicaid and get high if they do use opioids. Children’s Health Insurance Program Services at A person must stop taking opioids before being the Centers for Medicare and Medicaid Services, prescribed naltrexone. Those who take short- jointly urged increased use of MAT in treating acting naltrexone as directed do not relapse, opioid use disorders. They stated that, compared but most either refuse to take it or discontinue to behavioral therapy alone, MAT was cost- use. The sustained-release form of naltrexone effective, reduced criminal behavior, improved is administered once a month, which may social functioning, and for some medications, increase adherence to treatment and may work increased treatment retention (reduced relapse). well in court-supervised care. Without outside MAT generally begins in conjunction with supervision, six-month treatment retention behavioral therapy (Volkow et al., 2014).

3 Naloxone is an opiate receptor blocker that cannot be absorbed through the gastrointestinal tract. A potentially lifesaving drug, naloxone is also used intravenously or as a nasal spray to treat opioid overdose.

6 NDCI: The Professional Services Branch of NADCP Understanding and Detecting Prescription Drug Misuse and Misuse Disorders

Underutilization of MAT overdose toxicity by displacing opioids from their The following barriers contribute to low access to and binding sites. It is available in injection form and as a utilization of MATs (Matusow et al., 2013; Volkow et nasal spray, and the only indication for its use is opioid al., 2014): overdose. It rapidly revives a person who is unconscious • Many believe (mistakenly) that MATs merely replace one or losing consciousness from overdose, but the person addiction with another. typically revives in need of medical attention for acute opioid withdrawal. • The number of trained prescribers is insufficient, leading to improper dosing of MAT and treatment failure. In a rapidly growing number of states, it is now legal to prescribe naloxone to opioid users or, in some states, even • Many treatment-facility managers and staff members favor an abstinence (no-medication) model. However, dispense it to them with a pharmacist-issued prescription, opioid replacement retains patients in treatment and provided they and their families and friends have been decreases heroin use better than treatments that do not trained in its use by the prescriber or dispenser. Other use MAT (Mattick, Breen, Kimber, & Davoli, 2009). states have authorized police to carry naloxone, resulting in thousands of overdose reversals. • Policy and regulatory barriers are sometimes imposed by Medicaid programs or their managed-care organizations In states that permit naloxone to be carried on one’s that reduce use of MATs. These include limits on dosages person, a consensus is emerging that it should be available prescribed, annual or lifetime medication limits, initial in all households where anyone is using opioids regularly, authorization and reauthorization requirements, using them without medical supervision, or in danger minimal counseling coverage, and “fail first” criteria, of relapsing into opioid use. Their family members and which require that other therapies be attempted first friends should be trained to use naloxone. Former opioid (Rinaldo & Rinaldo, 2013). users leaving incarceration are at especially high overdose • Although most commercial insurance plans cover risk (Merrall et al., 2010), and many people argue they buprenorphine treatment (Volkow et al., 2014), coverage should leave with naloxone in hand where that is legal. may be limited. Drug courts supervising people with a history of opioid • Private insurance plans that provide coverage for the misuse or prescribed long-term use need to be aware of long-acting injection formulation of naltrexone are their state’s law governing naloxone and should encourage limited. Most plans do not cover methadone when it is its prescription where indicated. provided through opioid treatment programs. Too often, people do not seek medical assistance when As stated recently by the federal leaders of response to an overdose occurs for fear of being arrested for drug opioid use disorders, “Expanding access to MATs is a use, drug possession, or other drug-related crimes. To crucial component of the effort to help patients recover address this, some states have enacted overdose immunity [from opioid use disorders]. It is also necessary, however, laws intended to reduce the number of overdose-related to implement primary prevention policies that curb the deaths by encouraging people to seek help. These “Good inappropriate prescribing of opioid analgesics—the Samaritan” laws related to drug overdoses fall into two key upstream driver of the epidemic—while avoiding primary categories. The first encourages calling 911 jeopardizing critical opioid treatment when it is needed” to seek medical assistance for someone experiencing (Volkow et al., 2014). an overdose by providing criminal immunity for both the person in need and the person who sought help. Reversing Opioid Overdose with Naloxone The second provides varying levels of criminal or civil Overdose, largely from opioid drugs, is the leading immunity for those involved with the prescription, cause of injury death for Americans aged 25 to 64 years possession, or emergency administration of naloxone to (CDC, 2015). As mentioned previously, overdose kills reverse the effects of the overdose (National Conference by depressing breathing, and naloxone reverses opioid of State Legislatures, 2015).

Drug Court Practitioner Fact Sheet 7 Tranquilizers and Sedatives The prevalence of past-year nonmedical use of (Sedative-Hypnotics) sedative-hypnotics in the United States was 2.3%. Of those with nonmedical use, 9.8% met criteria While tranquilizers and sedatives (sedative- for use disorders (Becker, Fiellin, & Desai, 2007). hypnotics) represent different drug classifications, The most common sources of these medications they have similar side effects and are prescribed were friends or relatives, followed by physicians for similar medical conditions; therefore, they are and illegal sources (Inciardi et al., 2010). discussed together here (see Table 2). Tranquilizers calm and relieve anxiety. The first tranquilizer, Side Effects and Toxicity chlordiazepoxide hydrochloride (brand name: Sedative-hypnotics have dangerous side effects Librium), received FDA approval in 1960. related to central nervous system depression, Tranquilizers range in potency from mild to major, especially when taken in high doses or combined with increasing levels of drowsiness occurring as with alcohol or opioids. Regular use over a long potency increases. They are prescribed for a wide period of time may result in tolerance. Sedation variety of conditions but are used primarily to treat is the most common effect experienced when anxiety, insomnia, and alcohol withdrawal. taking BZDs. In healthy volunteers, increased Most tranquilizers are potentially addictive, sedation can be detected after each dose, even particularly those in the benzodiazepine (BZD) after a week of treatment. Tolerance appears family. Common BZDs include lorazepam (Ativan), to develop after a few weeks’ treatment, but oxazepam (Serax), clonazepam (Klonopin and some residual effects may remain, as increased Rivotril), alprazolam (Xanax), diazepam (Valium), alertness is reported by patients on stopping and clorazepate (Tranxene). Commonly available treatment with BZDs (Lader, 2011). sleeping pills include zolpidem (Ambien) and If long-acting BZDs are prescribed as hypnotic zopiclone (Imovane). The different BZDs have very (sleep-inducing) medications (e.g., nitrazepam similar actions; differences are related to duration [marketed under a number of brand names] and of action, depending on their metabolic half-life flurazepam [Dalmane]), the user experiences and the presence or absence of certain active definite residual effects the next day (Lader, 2011). metabolites. Sedative-hypnotics can cause significant dizziness, The sedative category includes barbiturates, also reduced psychomotor coordination, sedation, and called “barbs” or “downers.” They are used primarily memory impairment (Voyer, Roussel, Berbiche, for sedation and to treat insomnia. Commonly & Préville, 2010). Use of these drugs contributes misused barbiturates are secobarbital (Seconal) significantly to falls and motor vehicle crashes, and pentobarbital (Nembutal). A few sedative- two common causes of morbidity and mortality hypnotics do not fit in either category. They include (Division of Vital Statistics, 2014). Withdrawal meprobamate (Miltown, Equanil, Meprospan). from some of these medications after habitual use can induce seizures and death. Extent and Consequences of Misuse Barbiturates in high doses produce a characteristic Lifetime prevalence of nonmedical prescription syndrome of oversedation, with unsteadiness, poor drug use and drug use disorders for sedatives is coordination, slurred speech, and disorientation, estimated at 3.0% to 4.1% (Center for Behavioral and can cause death from respiratory depression. Health Statistics and Quality, 2015; Huang et al., The use of barbiturates and other sedative- 2006). Sedative use and misuse are associated with hypnotics with drugs that slow down the body, such psychopathology and suicide risk. Parental misuse as alcohol or opioids, multiplies their effects and of prescription medications is a strong predictor of greatly increases the risk of death. Most overdose sedative misuse (Goodwin & Hasin, 2002). deaths in the United States from sedative-hypnotic

8 NDCI: The Professional Services Branch of NADCP Understanding and Detecting Prescription Drug Misuse and Misuse Disorders

Table 2. Commonly Misused Sedative-Hypnotics and Their Applications

Generic name Brand name(s) Used to treat

Tranquilizers (benzodiazepines and sleeping aids)

alprazolam Xanax Anxiety, insomnia

clorazepate Tranxene Anxiety, insomnia

chlordiazepoxide Librium Anxiety, alcohol withdrawal, insomnia

clonazepam Klonopin, Rivotril Anxiety, insomnia

diazepam Valium Anxiety, insomnia

flurazepam Dalmane Insomnia

lorazepam Ativan Anxiety, insomnia

nitrazepam various Insomnia

oxazepam Serax Anxiety, insomnia

zolpidem Ambien Insomnia

zopiclone Imovane Insomnia

Sedatives (barbiturates)

pentobarbital Nembutal Insomnia, presurgical sedation

secobarbital Seconal Insomnia, presurgical sedation

Other sedative-hypnotics

meprobamate Equanil, Meprospan, Miltown Anxiety, muscle spasm or rigidity drugs involve combinations of depressant drugs (SAMHSA, disorders, impulse control disorder, and persistent alcohol 2014a). Overdose deaths can occur when barbiturates and problems. The combination of a BZD and alcohol is alcohol are used together, either deliberately or accidentally. particularly likely to lead to these hostile reactions. The BZDs alone are less likely to cause respiratory depression person may have complete or partial amnesia for the event. than opioids, but they can be lethal when mixed with Disinhibitory reactions are related to type of BZD, dose, alcohol, opioids, or sedatives. Many opioid overdose deaths and mode of administration (Bond, 1998). result from use in combination with BZD tranquilizers. In addition, nonmedical use of these medications may Paradoxical excitement and disinhibition occurs progress to a drug use disorder. In a cross-sectional analysis occasionally and is an unwanted effect that may have of respondents to the 2002–2004 National Survey on Drug legal consequences (Paton, 2002). This effect of BZDs Use and Health aged 18 and older, nearly 10% of those can produce increased anxiety, acute excitement and who reported past-year nonmedical use of tranquilizers or hyperactivity, and aggressive impulses, including hostility sedatives (approximately 490,000 people) met criteria for or rage. Estimates of the incidence of this effect range a drug use disorder (Becker et al., 2007). from less than 1% to 20% of those taking BZDs. High-risk Use of sedative-hypnotic drugs can adversely affect an patients include those with borderline personality unborn fetus. Like opioids and alcohol, these drugs pass

Drug Court Practitioner Fact Sheet 9 continue treatment, substitute with longer-acting medications, and work toward lowering the dose Common Signs of Sedative- to the minimum needed to attain a therapeutic Hypnotic Misuse/Overdose effect. Supportive psychotherapy is indicated • Unsteadiness to treat anxiety, insomnia, and other comorbid • Poor coordination disorders (O’Brien, 2005). • Slurred speech Stimulants • Disorientation • Respiratory depression Stimulants increase alertness and reduce fatigue. They also can activate the cardiovascular system. Prescription stimulants are primarily used in through the placenta. A mother’s misuse of sedatives the treatment of attention deficit hyperactivity during pregnancy can cause preterm birth, low disorder (ADHD), narcolepsy (a sleep disorder), birth weight, or fetal death, and may increase the binge-eating disorder, and obesity, and “off-label” risk of birth defects and later behavioral problems for depression, stroke rehabilitation, and traumatic (Bracken & Holford, 1981; Briggs, Freeman, & brain injury (Westover & Halm, 2012). Stimulants Yaffe, 2011; Källén, Borg, & Reis, 2013). Babies act by blocking reuptake of norepinephrine and born to mothers who misused sedatives during dopamine and by increasing their release into the their pregnancy may be physically dependent on extracellular space (Rothman et al., 2001). The most the drugs and show withdrawal symptoms after misused stimulants belong to the stimulant drug birth. Their symptoms may include breathing classification, which includes Adderall, Ritalin, problems, feeding difficulties, disturbed sleep, Vyvanse, and Concerta (see Table 3; Garnier- sweating, irritability, and fever. Dykstra, Caldeira, Vincent, O’Grady, & Arria, 2012). Adderall is reported as the most frequently Who Is Most at Risk for Use Disorder? misused prescription drug among college students Tranquilizer and sedative use is more common (Advokat, Guidry, & Martino, 2008; Johnston, among seniors and is more prevalent among O’Malley, Bachman, & Schulenberg, 2013; women than men (Becker et al., 2007). Other Lookatch, Dunne, & Katz, 2012). associated risk factors include past criminal Extent and Consequences of Misuse arrest, lack of health insurance, unemployment, alcohol use disorder, cigarette use, illicit drug use, Nonmedical use of prescription stimulants has younger age of initiating illicit drug use, and a become a significant public health concern, history of intravenous drug use. Those with use especially among young adults and adolescents. disorders are more likely to have agoraphobia (fear Rates of prescription stimulant misuse have soared of open spaces), be older, be unmarried, have a (Arria & Wish, 2006; Johnston et al., 2013; low education level, and have a history of arrest, McCabe, Teter, & Boyd, 2006; SAMHSA, 2009; compared with users without disorders. Teter, McCabe, LaGrange, Cranford, & Boyd, 2006). In 2012, about 1.1 million Americans reported Treatment using nonmedical prescription stimulants in the For those willing to discontinue use, treatment past year (SAMHSA, 2013b). Students give many involves gradually tapering the dose to reasons for using stimulants without a prescription, avoid serious withdrawal effects and treating which include to concentrate, improve alertness, withdrawal symptoms. If the person is unwilling ‘‘get high,’’ and experiment (Chen et al., 2014; to discontinue use, the physician may agree to Wilens et al., 2008).

10 NDCI: The Professional Services Branch of NADCP Understanding and Detecting Prescription Drug Misuse and Misuse Disorders

Table 3. Commonly Misused Stimulants and Their Applications

Generic name Brand name Used to treat

dextroamphetamine/amphetamine Adderall ADHD, narcolepsy

methylphenidate Ritalin ADHD, narcolepsy

lisdexamfetamine Vyvanse ADHD, binge-eating disorder

methylphenidate Concerta ADHD, narcolepsy

The number of people seeking emergency care because of Who Is Most at Risk for Stimulant stimulant misuse increased from 9,979 in 2004 to 40,648 Use Disorders? in 2011 (SAMHSA, 2013a). The highest rates of stimulant use are among 12- to The most common sources of stimulants were friends 25-year-olds (SAMHSA, 2012). In one literature review, or relatives, followed by physicians and illegal sources. prevalence estimates across studies ranged from 5% to Sharing was the most common method of diversion, with 10% for high school students and 5% to 35% for college 33.6% of students sharing their prescription medications students (Clemow & Walker, 2014). A second literature and 9.3% having sold them (Garnier et al., 2010). review associated fraternity or sorority membership, poor academic performance, and other substance use with Side Effects and Toxicity misuse (Benson, Flory, Humphreys, & Lee, 2015). Signs When stimulants are used as prescribed, side effects may of stimulant misuse (side effects of the drugs) include include nervousness, headache, insomnia, anorexia, and nervousness or acting “jittery,” dry mouth, loss of appetite tachycardia (rapid heart rate). Symptoms increase with or weight loss, sleep problems, stomach pains or diarrhea, headaches, dizziness, skin lesions from scratching, and increasing doses. Clinical manifestations of overdose dental problems. include agitation, hallucinations, psychosis, lethargy, seizures, tachycardia and other heart rhythm abnormalities, high blood pressure, and increased body temperature (Klein-Schwartz, 2002). Chronic use may lead to infection, Common Signs heart failure, malnutrition, and permanent psychiatric illness (Richards et al., 1999). Stimulant misuse has also of Stimulant Overdose been linked to heart and blood vessel problems, drug use • Agitation disorders, other high-risk behaviors such as unsafe sex, • Hallucinations and alcohol-related injuries. More than half of college • Psychosis students who reported misuse of Adderall in the past year • Lethargy were heavy alcohol users (Lakhan & Kirchgessner, 2012). • Seizures When taken during pregnancy, stimulants can cause • Tachycardia and other heart rhythm elevated body temperature, seizures, fast or irregular abnormalities heartbeat, high or irregular blood pressure, sleep problems, • High blood pressure tremors, weight loss, and panic attacks in the mother. Stimulants can cause preterm birth or fetal death, increase • Increased body temperature maternal blood pressure, and increase risks of brain defects, (Klein-Schwartz, 2002) heart defects, and cleft lip/palate in the fetus (Briggs et al., 2011; Bracken & Holford, 1981).

Drug Court Practitioner Fact Sheet 11 Treatment General Screening There are no FDA-approved medications to treat Screeners for substance misuse may be general— stimulant use disorder. A stepped approach is best, asking about tobacco, alcohol, illegal drug, and beginning with brief interventions and short-term prescription drug use—or specific to only one follow-up. If brief interventions are insufficient, substance or class of drugs. General screeners then treatment services with long-term follow-up for substance misuse and use disorder detection may be needed. Treatment can include individual or typically are used for universal health screening. group therapy or intensive outpatient or inpatient Most were developed to be administered by medical treatment. Moderately effective interventions professionals, but they could be adopted for use by typically use cognitive behavioral skills training and court staff if they are answered honestly. supportive, motivational interviewing approaches The Clinician’s Pocket Guide for Drugs, Alcohol, and (Vocci & Montoya, 2009). Some evidence suggests Tobacco Screening, Brief Intervention, Referral and that contingency management interventions can help Treatment 4 recommends the following screener to to improve retention in treatment and, in turn, other detect prescription drug misuse: treatment outcomes. Although there are important 1. “Have you ever taken prescription medication that differences in the neuropsychiatric and medical was not prescribed for you or in a way that was consequences of cocaine and amphetamine use not prescribed?” (Any “yes” is a positive screen.) disorders, similar psychosocial treatment approaches If “yes,” ask: are effective. 2. “Tell me more about that…” or “Did you do this Identifying Prescription Drug Abuse only for the feeling/experience that is caused or to ‘self-medicate’?” Traditionally, Drug Court staff have relied on biological drug testing to detect drug users. Short 3. “Have you done this in the past 3 months?” questionnaires (20 items or fewer) can also be used for this purpose. Screeners are short questionnaires Opioid Screening that identify potential prescription drug use A number of brief screeners are being developed to problems. Screening can help prevent misuse predict risk of developing prescription drug misuse of prescription drugs, identify those at risk, and among patients seeking opioid medications to discover a potential addiction problem or point control pain. The National Institute on Drug Abuse to a need for further evaluation and treatment. has a screener available on its website (National Question-based screeners could be useful in helping Institute on Drug Abuse, 2012). For those already judicial staff to recognize and deal effectively with being prescribed opioids, risk factors for detecting a prescription drug misuse. Screening for prescription current drug use disorder include selling prescription drug misuse is performed for two reasons: drugs, forging prescriptions, stealing drugs, injecting • To identify people at high risk for developing oral formulations, obtaining prescription drugs from prescription drug use disorders nonmedical sources, concurrently abusing alcohol • To determine whether an individual shows key and illicit substances, escalating doses on multiple indicators of a prescription drug use disorder occasions despite warnings, claiming to have lost prescriptions on multiple occasions, repeatedly Screeners are developed to correctly identify people seeking prescriptions from other providers without with and without a condition. Screeners with a solid informing the provider or after warnings to desist, research base are recommended because scientific and showing evidence of deteriorating function due evidence supports their accuracy (Akobeng, 2007). to drug use (Manubay, Muchow, & Sullivan, 2011).

4 Available at www.wvmphp.org/247635_WVU_SOM_Pkt_Guide_Single_Pgs-1127.pdf

12 NDCI: The Professional Services Branch of NADCP Understanding and Detecting Prescription Drug Misuse and Misuse Disorders

Stimulant Screening disorder. If seniors answer yes to both of the following questions, the researchers estimate a 97% possibility that Currently, no brief specific screeners are geared to detect the respondent is BZD dependent: stimulant misuse, although a 37-item questionnaire has been developed to identify risks for stimulant misuse • “Have you tried to stop taking this medication?” and use disorder among college students (Bavarian, Flay, • “Over the past 12 months, have you noticed any decrease Ketcham, & Smit, 2013). in the effect of this medication?” Voyer and colleagues (2010) have developed a two-question Respondents who answer no to either or both questions are screener for older adults to detect benzodiazepine use 95% likely not to be BZD dependent.

Resources

Drug Misuse in the Workplace opioid-related overdoses and deaths, and addresses issues for first responders, treatment providers, and those recovering To address prescription drug misuse in the workplace, SAMHSA established the Preventing Prescription Abuse from opioid overdose. It is available at store.samhsa.gov/ in the Workplace (PAW) program. This program provides product/Opioid-Overdose-Prevention-Toolkit-Updated-2014/ technical assistance to workplaces and SAMHSA grantees SMA14-4742 across America to reduce prescription drug misuse. PAW has developed more than 30 fact sheets and issue briefs, Additional Resources including the following: Screening resources • How to Handle Leftover Meds The NIDA Quick Screen: www.drugabuse.gov/publications/ • Managing Chronic Low Back Pain While Minimizing Use resource-guide-screening-drug-use-in-general-medical-settings/ of Dangerous Prescription Opioids nida-quick-screen • Pregnancy and Prescription Drug Abuse SAMHSA’s Screening, Brief Intervention, and Referral to • Prescription Drug Misuse among College Students Treatment: www.integration.samhsa.gov/clinical-practice/SBIRT • Prescription Drug Misuse among Older Adults: Understanding the Problem List of commonly misused drugs • Screening for Prescription Drug Use Problems www.drugabuse.gov/drugs-abuse/commonly-abused-drugs-charts These fact sheets are available at publichealth.hsc.wvu.edu/ FAQ on sedative-hypnotics icrc/prevention-of-prescription-drug-abuse-in-the-workplace/ samhsa-fact-sheets www.well.com/user/woa/fsseda.htm

Opioid Toolkit Information on medication-assisted treatment SAMHSA has also produced an Opioid Toolkit, which equips communities and local governments with www.samhsa.gov/medication-assisted-treatment material to develop policies and practices to help prevent www.drugabuse.gov/sites/default/files/tib_mat_opioid.pdf

Drug Court Practitioner Fact Sheet 13 References

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14 NDCI: The Professional Services Branch of NADCP Understanding and Detecting Prescription Drug Misuse and Misuse Disorders

Compton, W.M., & Volkow, N.D. (2006). Abuse of Johnston, L.D., O’Malley, P.M., Bachman, J.G., & Schulenberg, prescription drugs and the risk of addiction. Drug and Alcohol J.E. (2013). Monitoring the Future—National survey results on Dependence, 83(S1), S4–S7. drug use, 1975–2012: Volume 2, College students and adults ages 19–50. Ann Arbor: Institute for Social Research, University Division of Vital Statistics, National Center for Health Statistics, of Michigan. Centers for Disease Control and Prevention. (2014). Deaths, percent of total deaths, and death rates for the 15 leading causes of Jones, H.E., Kaltenbach, K., Heil, S.H., Stine, S.M., Coyle, death in 5-year age groups, by race and sex: United States, 2013. M.G., Arria, A.M., ... & Fischer, G. (2010). Neonatal abstinence Hyattsville, MD: Author. syndrome after methadone or buprenorphine exposure. New England Journal of Medicine, 363(24), 2320–2331. Express Scripts Lab. (2014). A nation in pain: Focusing on U.S. opioid trends for treatment of short-term and longer-term pain. St. Jones, J.D., Mogali, S., & Comer, S.D. (2012). Polydrug abuse: Louis, MO: Express Scripts. A review of opioid and benzodiazepine combination use. Drug and Alcohol Dependence, 125(1), 8–18. Garnier, L.M., Arria, A.M., Caldeira, K.M., Vincent, K.B., O’Grady, K.E., & Wish, E.D. (2010). Sharing and selling of Joseph, H., Stancliff, S., & Langrod, J. (2000). Methadone prescription medications in a college student sample. The maintenance treatment (MMT): A review of historical and Journal of Clinical Psychiatry, 71(3), 262–269. clinical issues. The Mount Sinai Journal of Medicine, New York, 67(5–6), 347–364. Garnier-Dykstra, L. M., Caldeira, K. M., Vincent, K.B., O’Grady, Källén, B., Borg, N., & Reis, M. (2013). The use of central K. E., & Arria, A. M. (2012). Nonmedical use of prescription nervous system active drugs during pregnancy. Pharmaceuticals, stimulants during college: Four-year trends in exposure 6(10), 1221–1286. opportunity, use, motives, and sources. Journal of American College Health, 60(3), 226–234. Klein-Schwartz, W. (2002). Abuse and toxicity of methylphenidate. Current Opinion in Pediatrics, 14(2), 219–223. Goodwin, R.D., & Hasin, D.S. (2002). Sedative use and misuse in the United States. Addiction, 97(5), 555–562. Knudsen, H.K., Abraham, A.J., & Roman, P.M. (2011). Adoption and implementation of medications in addiction Huang, B., Dawson, D.A., Stinson, F.S., Hasin, D.S., Ruan, W., treatment programs. Journal of Addiction Medicine, 5(1), 21–27. Saha, T.D., ... & Grant, B.F. (2006). Prevalence, correlates, and comorbidity of nonmedical prescription drug use and drug Lader, M. (2011). Benzodiazepines revisited—Will we ever use disorders in the United States: Results of the National learn? Addiction, 106(12), 2086–2109. Epidemiologic Survey on Alcohol and Related Conditions. Lakhan, S.E., & Kirchgessner, A. (2012). Prescription stimulants Journal of Clinical Psychiatry, 67(7), 1062–1073. in individuals with and without attention deficit hyperactivity Inciardi, J.A., Surratt, H.L., Cicero, T.J., Rosenblum, A., Ahwah, disorder: Misuse, cognitive impact, and adverse effects. Brain C., Bailey, J.E., ... & Burke, J.J. (2010). Prescription drugs and Behavior, 2(5), 661–677. purchased through the Internet: Who are the end users? Drug Lookatch, S.J., Dunne, E.M., & Katz, E.C. (2012). Predictors and Alcohol Dependence, 110(1), 21–29. of nonmedical use of prescription stimulants. Journal of Ives, T.J., Chelminski, P.R., Hammett-Stabler, C.A., Malone, Psychoactive Drugs, 44(1), 86–91. R.M., Perhac, J.S., Potisek, N.M., ... & Pignone, M.P. (2006). Manchikanti, L. (2006). Prescription drug abuse: What is being Predictors of opioid misuse in patients with chronic pain: A done to address this new drug epidemic? Testimony before the prospective cohort study. BMC Health Services Research, 6, Subcommittee on Criminal Justice, Drug Policy and Human article 46. Resources. Pain Physician, 9(4), 287–321. Jenkins, L.M., Banta-Green, C.J., Maynard, C., Kingston, S., Manubay, J. M., Muchow, C., & Sullivan, M.A. (2011). Hanrahan, M., Merrill, J. O., & Coffin, P.O. (2011). Risk factors Prescription drug abuse: Epidemiology, regulatory issues, for nonfatal overdose at Seattle-area syringe exchanges. Journal chronic pain management with narcotic analgesics. Primary of Urban Health, 88(1), 118–128. Care: Clinics in Office Practice, 38(1), 71–90.

Drug Court Practitioner Fact Sheet 15 References (continued)

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Drug Court Practitioner Fact Sheet 17 The Professional Services Branch of NADCP 1029 N. Royal Street, Suite 201 Alexandria, VA 22314 Tel: 703.575.9400 Fax: 703.575.9402

This publication is a collaborative product developed by the Preventing Prescription Abuse in the Workplace (PAW) Technical Assistance Center of the Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Prevention, Division of Workplace Programs. It was funded by SAMHSA contract task order HHSS283200700012I/HHSS28342001T. Points of view or opinions in this document are those of the author and do not represent the official position or policies of the funding agency.